Government weighs in on debate over kratom

Laurie McGinley, Katie Zezima The Washington Post

Thursday

Feb 15, 2018 at 3:00 AM

Rapidly rising in popularity, kratom is hailed as a readily available pain remedy that is safer than traditional opioids (such as oxycodone), an effective addiction withdrawal aid and a pleasurable recreational tonic. Kratom also is assailed as a dangerous and unregulated drug that can be purchased on the Internet, a habit-forming substance that authorities say can result in opioid-like abuse and death.

Andrew Turner's years in the military left him suffering from post-traumatic stress disorder, anxiety, back pain and the effects of an injury that mangled his hand. "I was a broken toy," he said. Tossed aside. Barely able to get off the couch.

Then he started using an herbal supplement that he says saved his life: kratom.

Nancy Knoebel's 27-year-old son began using kratom after he stopped taking medication to treat his heroin addiction. But he was having withdrawal symptoms, so he turned to an herbal remedy. Within a few months, Knoebel's son was dead from what a medical examiner determined were the "toxic effects" of kratom.

Rapidly rising in popularity, kratom is hailed as a readily available pain remedy that is safer than traditional opioids (such as oxycodone), an effective addiction withdrawal aid and a pleasurable recreational tonic. Kratom also is assailed as a dangerous and unregulated drug that can be purchased on the Internet, a habit-forming substance that authorities say can result in opioid-like abuse and death.

Now, the compound is at the center of an acrimonious battle on social media, in federal agencies and at all levels of government – a fight over whether kratom could help curb the nation's opioid epidemic or make it dramatically worse.

The Drug Enforcement Administration is weighing whether to place kratom, which comes from a leafy Southeast Asian tree, in the same category of illegal drugs as heroin. It's the second time the agency has tried to curb access to kratom, delaying a final decision in 2016 after an outcry from the public, dozens of members of Congress and a demonstration at the White House.

This time, the DEA is getting high-profile support for a crackdown from the Food and Drug Administration, which has repeatedly warned about the dangers of the substance and says it has identified 44 deaths associated with its use since 2011. On Tuesday, the agency said the new computer model it developed shows that kratom contains opioid compounds with potentially deadly side effects such as seizures and depressed breathing. The FDA emphasizes that there is no evidence that kratom is safe for any medical use, including for the treatment of opioid withdrawal symptoms.

"Claiming that kratom is benign because it's 'just a plant' is shortsighted and dangerous," FDA Commissioner Scott Gottlieb said in statement. "After all, heroin is an illegal, dangerous, and highly addictive substance" derived from opium poppies.

Gottlieb's stance has sparked a torrent of criticism from kratom backers. The American Kratom Association, a nonprofit organization that promotes access to kratom, called the FDA's model "garbage in, garbage out." The group contends that the agency's conclusions contain "clear mistakes," including the allegation that the compound can cause breathing problems.

Some scientists worry that a ban could shut down research on kratom as a potentially important pain medication while leaving current users without safe alternatives.

Scientists think that kratom binds to opioid receptors in the brain, leading to pain relief and possibly an aversion to traditional opioid drugs.

"It seems like a lot of people have used kratom to get off more dangerous opioids or to treat intractable pain not managed successfully with drugs," said Columbia University research chemist Andrew Kruegel, who has authored studies on the pharmacology of botanics. "And if you take their lifeline, some fraction may go back to heroin or fentanyl or even prescription opioids."

Bertha Madras, a professor of psychobiology at Harvard Medical School, said such claims that kratom is beneficial are not scientifically substantiated. There haven't been any human clinical trials that show definitively how kratom acts in the body or how it interacts with other drugs.

"I support the FDA on this," Madras said. "I really believe they have taken a cautionary stance, which is to protect the American public."

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The tropical tree causing the furor, Mitragyna speciosa, is native to countries including Indonesia, Malaysia and Thailand. A member of the coffee family, kratom was long popular with Southeast Asian farmworkers who would take it to boost productivity and as a substitute for opium. Taken in small doses, kratom acts as a stimulant; at higher doses, it can be used for sedation.

Kratom surfaced in the United States about a decade ago; an estimated 3 million to 5 million people use it, according to the American Kratom Association. People consume it by swallowing capsules of finely ground powder, drinking kratom tea or chewing and swallowing the plant's bitter leaves. Some "toss and wash" by putting a clump of powder in their mouths, followed by a slug of water.

Essentially unregulated, kratom is widely available on the Internet and is sold in some head shops, gas stations and corner stores. It has been banned for sale and possession in at least five states and in several cities, including the District and San Diego.

Depending on how it is marketed, the FDA considers kratom either an unapproved drug or a new dietary ingredient whose safety has not been proved, making it subject to enforcement actions, including seizure.

In August 2016, the DEA announced plans to temporarily place kratom's active materials in Schedule 1 of the Controlled Substances Act "to avoid an imminent hazard to public safety." It said kratom had a high potential for abuse, did not have any currently accepted medical use and was not considered safe even when used under medical supervision.

The agency received more than 23,000 comments, mostly negative, along with complaints from dozens of members of Congress, spurring it to withdraw the plan to wait for a comprehensive medical evaluation and recommendation from the FDA.

While the FDA's assessment has not been released, Gottlieb has made it clear that he does not want to repeat the agency's past mistakes in failing to put the brakes on the opioid crisis. "We've learned a tragic lesson from the opioid crisis, that we must pay early attention to the potential for new products to cause addiction and we must take strong, decisive measures to intervene," he said late last year.

Marc Swogger, a clinical psychologist at the University of Rochester Medical Center who has studied the plant, has said that the government's attitude toward kratom is "drug hysteria." He and others also are skeptical of the estimated death toll from kratom.

"It's all anecdotal, and in many cases other substances were involved," Swogger said. "It's just very, very poor evidence." The list of 44 deaths, for example, includes nine cases in Sweden in which kratom was laced with a powerful opioid, and just one in which kratom was the only substance present.

Madras worries that the number of deaths associated with kratom could be much higher than the FDA's count because "nobody monitors it" and because medical examiners aren't doing toxicology screenings to find it.

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For Turner, the problem wasn't addiction. It was pain, anxiety and depression. By early 2015, he was barely able to leave his house in Hyattsville, Maryland, and he decided to take a drastic step: He quit his prescription pain medications and tried kratom, which he found online.

After his third time using kratom, he noticed that his mood was brightening. His pain subsided, his anxiety eased and his energy surged.

"I feel like I have gotten my life back," said Turner, 44, who is no longer on Social Security disability, has started a weekly podcast and is thinking of running for city council.

He now makes weekly batches of kratom tea and drinks two cups a day. He says he could probably get high from taking kratom if he took enough, but he adds: "That's not what I'm looking for."

Megan George of Lexington, North Carolina, was prescribed opioids for chronic pain until a doctor told her that she no longer needed them. Desperate and in withdrawal, she turned to heroin and quickly became addicted. She tried for years to quit by using medications for opioid addiction, but she never succeeded.

Last April, George, 31, tried kratom and says she has not used heroin since. In the past 10 months, she has held down her first job in years and is finally the parent she dreamed of being to her 2-year-old daughter.

"I'm going to work, I'm making money and coming home to her," George said. "It's great. It's amazing."

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A few years after being treated for drug problems, Knoebel's son, Daniel Teichman, had a college degree, a good job and an apartment. An avid traveler and history buff, he loved to ski, hike and meditate.

But at a family reunion in 2014, he kept nodding off, finally telling his mother the devastating truth. He had become addicted to heroin.

"It was like a dagger being plunged into my heart," said Knoebel, of Bethlehem, Pennsylvania.

After battling his way back to sobriety, Teichman moved to Portland, Oregon, and he became active in the large recovery community there. He decided to pursue a graduate degree in computer science and went on suboxone, a treatment for opioid addiction, to reduce his risk of relapse.

Encouraged by his progress, he stopped taking suboxone in spring 2016 but was plagued by recurring withdrawal symptoms, including insomnia. His mother bought him a new mattress to help him sleep better. He told her he had found an "herbal remedy" that seemed to help.

That fall, his sister Rebecca found him dead in his bed in the apartment they shared. A toxicology examination of his blood found a high level of mitragynine, one of the active ingredients in kratom, as well as small amounts of other drugs, including an antidepressant and a mild stimulant. Karen Gunson, Oregon's chief medical examiner, said that kratom caused Teichman's death from respiratory depression.

"This is not a magic drug that has no side effects," Gunson said. She blames kratom for three deaths in Oregon in the past two years.

When she suspects kratom is involved in a death, Gunson sends blood samples to NMS Labs, a forensic laboratory in Willow Grove, Pennsylvania. Barry Logan, a senior vice president at NMS, said kratom is increasingly showing up in samples and he has "no doubt that at high doses it is causing death."

But he also said it can be difficult to pinpoint kratom's role in a death, especially when combined with other drugs - which is frequently the case - because of a lack of testing on humans.

Some former users say kratom can be addictive. One 38-year-old Ohio man, who spoke on the condition of anonymity because he does not want his addiction made public, said kratom was fun - it was like "having morphine and cocaine at the same time" - until he got addicted. Withdrawal, he said, was like "getting ripped apart by fishhooks."

Buyers also can't be sure of what they are getting. Some kratom products are much more powerful than others or are laced with hydrocodone - a moderately narcotic painkiller - and other substances.

Kratom is also relatively inexpensive, going for about $9 to $20 per ounce online, depending on the strain.

The dichotomy of its potential to help and its potential to kill - not unlike well-known opioids - explains the embrace and fear that surrounds kratom.

Edward Boyer, an associate professor of emergency medicine at Harvard Medical School, who has studied kratom, echoes that sentiment and notes that two things stand out about the plant.

"The first is that kratom, I think, can be effective in treating opioid withdrawal," he said. "The second thing is you can become addicted to kratom just as you could any other opioid. It's not a magic bullet, it's not a panacea."

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Video: What is Kratom? Find out why the FDA says this herb is an opioid.